- SERVICE PROVIDER
Devon Partnership NHS Trust
This is an organisation that runs the health and social care services we inspect
We served a warning notice on Devon Partnership NHS Trust on 5 June 2025 as the quality of health care provided needs significant improvements in Forensic inpatient or secure ward services at Langdon Hospital.
Assessment report published 21 November 2025
Contents
Ratings - Forensic inpatient or secure wards
Our view of the service
We carried out an unannounced, focused, responsive inspection of the forensic inpatient and secure wards at Langdon Hospital. This inspection was undertaken in response to concerns raised by both internal and external sources regarding the safety of people using the service and the effectiveness of leadership within the service.
At our previous inspection in 2021, we rated the service as Requires Improvement overall. This included the key questions of Safe, Effective, and Well-led.
During this inspection, we visited all 5 wards at Langdon Hospital to assess the quality and safety of care being provided. We focused our assessment on the key questions of Safe, Effective, and Well-led.
Following this inspection, we have again rated the service as Requires Improvement overall. Each of the key questions assessed were also rated as Requires Improvement.
We identified 5 breaches of the regulations. These related to person-centred care, dignity and respect, safe care and treatment, good governance, and staffing.
As a result of breaches relating to good governance and, safe care and treatment, we issued a Warning Notice under Section 29A of the Health and Social Care Act 2008 which required the service to make significant improvements to the quality of the health care they provided.
Additionally, where concerns did not meet the threshold for inclusion in the Warning Notice, we have asked the provider for an action plan in response to the concerns found at this assessment.
Devon Partnership NHS Trust, established in 2001, is a specialist mental health provider, delivering mental health, learning disability, and neurodiversity services from community and hospital-based settings across Devon and the broader Southwest region.
The trust serves a population of approximately 953,800 residents covering an area of 2600 square miles. The trust covers an area that is predominantly rural with areas of urban development along its north and south coastlines.
In October 2020, the trust assumed the role of lead provider for the Southwest Provider Collaborative (SWPC), a regional partnership responsible for commissioning services including those of forensic and secure mental health. This involved the trust taking on commissioning responsibilities for the care of approximately 350 adults with medium and low secure mental health needs. The Collaborative had 8 partners, including 5 NHS organisations, 1 community interest organisation and 2 independent hospitals. The geographical area was vast covering approximately 9,266 square miles, spanning from the Isles of Scilly to Gloucestershire (a catchment population of over 5 million people).
During our inspection, people using the service told us they did not always feel involved in decisions about their care or risk assessments. Care plans often lacked evidence of person-centred care and did not reflect individuals’ current needs. In some cases, staff used a specific risk assessment tool inconsistently, leading to restrictions that people using the service experienced as unfair or punitive.
The ward environments included blind spots that staff had not formally assessed or mitigated. The design of seclusion and extra care areas did not always protect people’s privacy or dignity. Staff told us they were not always sure what happened after incidents, and staff also said they were not clear on how learning was shared or acted upon.
Staff found it difficult to use the trust’s digital systems to record or access care information effectively. They also had not received training in how to assess or manage non-clinical risks. Many staff lacked awareness of ligature risks, and the tools available did not help them to identify or prioritise those risks. Staff had not received the enhanced training needed to effectively care for autistic people, despite people with those needs being supported on the wards.
Staff also told us there were not always enough staff to meet people’s needs, especially during busy or unpredictable periods of increased acuity. This made it harder to maintain specialist roles and deliver consistent care to people.
However, since our last inspection, in response to a requirement notice we had issued, we found the trust had taken action to improve the monitoring of people’s physical health. Staff now completed this documentation more accurately and consistently, which enabled them to identify early signs of deterioration. As a result, they were able to take timely and appropriate action to support the health and wellbeing of people using the service.
The Occupational Therapy programme received strong praise from people who used the service, who told us it felt valued and had a positive impact on their care and treatment.
Staff across the service demonstrated openness and a willingness to speak up. There was a strong sense of transparency and a supportive team culture.
Staff in developmental roles, including Nursing Associates and those on Nursing Apprenticeship pathways, were being given opportunities to grow and develop their skills within the service.
Overall, people using the service expressed significant frustration with the pace of their care and treatment, particularly the perceived lack of progress within the care pathway and delays in discharge planning. Many people using the service felt their care plans did not reflect their personal goals or were not shared with them in a meaningful way.
Access to staff, including doctors, was reportedly inconsistent, with some people using the service reporting positive relationships and regular reviews, while others described difficulty in accessing medical staff and having a lack of involvement in treatment decisions. People using the service frequently reported perceived staff shortages impacted their access to leave and activities, which to them were highly valued aspects of their care experience.
Communication was a recurring theme of concern. People using the service described inconsistent messaging, lack of transparency around care decisions, and a general sense that their voices were not being heard. Some people using the service reported fear of retaliation for raising complaints, and several described the complaints process as ineffective or inaccessible.
The use of a specific risk assessment tool was widely criticised. People using the service felt it was being used punitively, without explanation or discussion, and that it contributed to the loss of leave or privileges without due process. There was a strong perception that restrictions were applied inconsistently, and people using the service felt these were petty or overly rigid.
Despite these concerns, people using the service consistently praised the Occupational Therapy (OT) team and some individual staff members for their dedication and support. The OT team was credited with enabling much of the leave that people were able to access.
However, people using the service we spoke with reported feeling physically safe and described the environment as clean and well maintained.